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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME ADDRESS T� �J_ CITY <br /> OWNER NAME OWNER PHONE j# 2A [ uc <br /> 7�Do d <br /> CONTRACTOR CONT. PHONE q/l0 <br /> - 252 - 0302 <br /> FIRE PERMIT S /3 5/ <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE _ <br /> INSPECTOR DATE TANK 39 /1 2-7 i <br /> IRINSED ON) METHOD �� �—� � RINSE AMOUNT 12,5- <br /> N RINSATE DISPOSAL SITE iQpyH� <br /> S <br /> E MANIFEST , OR OTHER <br /> FAV VAPORS PURGED (Y N) METHOD AMOUNT IISED Cf� <br /> P IREADING AT REMOVAL L.E.L. : 02 : <br /> O <br /> R I COMMENTS 6051,2) 2 <br /> C TANK MATERIALSTE FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION GOO POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL FIBERGLAS , OTHER) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> T DEPTH SOIL TYPE OBSERVATION SAMPLE 0 <br /> A Oc. va[ <br /> N <br /> K 's <br /> SEXCAVATION SIZE 6 �U X (j YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> H DEPTH TO G.W. : FT. SAMPLING METHOD <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />